Background Verification/Field Investigation/Release of Information
I authorize MTA Bridges and Tunnels (legal name, Triborough Bridge and Tunnel Authority) and all contractors performing background
investigation services for MTA Bridges and Tunnels or any of their agents to procure an investigative consumer report for employment
purposes, which may include information about my character, background, general reputation, personal characteristics, credit
worthiness, or mode of living and may also include personal interviews with my present and former employers, present and former
neighbors, friends, associates, and others acquainted with me. I understand that before adverse action, including the denial of my
employment, can be taken against me in whole or in part due to a consumer report, I will be provided with a copy of the report and a
written summary of my rights under the Fair Credit Reporting Act. I also understand I may have additional rights under applicable state
law.
I authorize all persons, corporations, companies, credit agencies, educational institutions, present and former employers federal,
state, and local government agencies, law enforcement agencies, workers’ compensation agencies, criminal, civil, and federal courts,
and military services (Information Sources) to release any information they may have about me to MTA Bridges and Tunnels and all
contractors performing background investigation services for MTA Bridges and Tunnels or any of their agents. I release all Information
Sources from any liability for releasing such information.
If hired, this authorization shall remain on file and serve as an ongoing authorization for MTA Bridges and Tunnels and all contactors
performing background investigation services for MTA Bridges and Tunnels or any of their agents to procure consumer reports at any
time during my employment. Any copy of this authorization shall have the same authority as the original.
Candidate’s Authorizing Signature: Date:
Candidate Information
Last Name: First Name: Mid. Init.: Maiden or Other Name Used:
Social Security Number: Date of Birth:
Address Information. Please provide your current address first, then provide your previous addresses (if applicable) for the last seven years.
Current Street Address: Lived as this address since (Mo/Yr)
City: State: Zip Code:
Previous Street Address: Lived at this Address From (Mo/Yr) Lived at this Address Until (Mo/Yr)
City: State: Zip Code:
Previous Street Address: Lived at this Address From (Mo/Yr) Lived at this Address Until (Mo/Yr
City: State: Zip Code:
Previous Street Address: Lived at this Address From (Mo/Yr) Lived at this Address Until (Mo/Yr
City: State: Zip Code:
Driver License Information
Driver License Number: Issuing State: Expiration Date:
This information will be used for purposes of identification and will not be used for discriminatory purposes. Federal law prohibits
discrimination in employment on the basis of age, race, color, creed, religion, sex, disability, or national origin.
Revised: 01/03/2017 Page 1
Background Verification/Field Investigation/Release of Information
NOTIFICATION UNDER THE PERSONAL PRIVACY PROTECTION LAW
As a prospective, newly-hired or promoted employee of MTA Bridges and Tunnels (legal name, Triborough Bridge and Tunnel
Authority), you are required to accurately complete, swear to, and submit this form. The information you supply is subject to
written, telephone, and personal verification. You are required to sign an authorization for MTA Bridges and Tunnels to obtain
certain information.
The information is requested pursuant to the general powers of MTA Bridges and Tunnels and will principally be used to evaluate
your background and qualifications with respect to the position for which you have applied. The information about you which is
obtained in connection with your background verification will be maintained by the Human Resources
Department of MTA Bridges and Tunnels at 2 Broadway, 22nd Fl. New York, New York 10004 in care of the Director, Human
Resources. The information submitted may be disclosed to officers, employees, and contractors of the MTA Bridges and Tunnels,
its affiliates, and subsidiaries in connection with the performance of official duties, and to others in connection with the purpose
for which the information is collected. Except as disclosure is permitted under New York State Personal Privacy Protection Law
(Public Officers Law Article 6-A), the information submitted by you shall be deemed to have been submitted by you in confidence
unless you otherwise notify the MTA Bridges and Tunnels. Contact the Director, Human Resources for further information as to
such notification.
A false statement or intentional omission of any material fact on this application may cause you to be disqualified, dismissed even
following your employment, and may lead to prosecution.
Candidate’s Authorizing Signature: Date:
Candidate Information
Last Name: First Name: Mid. Init. Social Security Number:
Revised: 01/03/2017 Page 2
